UMEM Educational Pearls

Title: "Food poisoning": How do you like your fish?

Keywords: ciguatera, scromboid, tetrodotoxin (PubMed Search)

Posted: 9/18/2014 by Hong Kim, MD
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Food poisoning can occur with many different food groups/items, as well as how the food is prepared, handled or stored.

There are three specific “food poisonings” associated with fish consumption can cause serious toxicity/illness beyond GI symptoms: Ciguatera, Scrombroid, tetrodotoxin (puffer fish)

Ciguatera

Endemic to warm tropical water and bottom reef dwelling large carnivorous fish: grouper, red snapper, barracuda, amberjack, parrot fish, etc. (> 500 species).
Toxin: ciguatoxin: opens voltage gated Na channel
Produced by dinoflagellates (gambierdiscus toxicus) and bioaccumulates in large fish through food chain (eating small fish).

Symptoms:

GI symptoms: n/v/d and abdominal pain
Hot/cold reversal
Paresthesia of tongue/lip >> extremities
Dental pain: “loose teeth”

May progress to develop…

T wave changes, bradycardia, hypotension
Respiratory paralysis and pulmonary edema

Treatment: supportive care and mannitol in presence of severe neurologic symptoms (limited evidence).

Scrombroid

Endemic in (dark meat) fish living in temperate or tropical water: amberjack, skipjack, tuna, mackerel, albacore, mahi mahi, etc.
Associated with poor refrigeration/storage after catching fish.
Histidine in tissue is converted to histamine by bacteria on the fish skin.

Symptoms:

GI symptoms: n/v/d and abdominal pain
Upper body flushing
Puritis, urticarial and perioral swelling can occur
Palpitation and mild hypotension

Tx: H1/H2 blockers and supportive care

Serious reactions: treat like allergic/anaphylactic reaction

Tetrodotoxin

Ingestion of improperly prepared puffer fish (fugu) sushi (or bite from blue ring octopus)
Toxin: tetrodotoxin: blocks voltage gated Na channel.
Highest concentration in liver and ovary.

Symptoms:

GI: n/v/d
Progressive paresthesia and weakness (bulbar-> extremities), ataxia
Ascending paralysis and respiratory distress/paralysis
Dysrythmia and hypotension
Mental status preserved.

Treatment: supportive care and intubated if needed.